Scenario: Patient presented with new onset elevated blood pressure in her 34 weeks of gestation. On thorough history; patient is having headaches, visual disturbances, and abdominal pain. Urine analysis showed proteinuria
» Clinical features of severe pre-eclampsia?
- Headache (most commonly the posterior part of the head is hypo perfused -> occipital headache)
- Visual changes (flashing lights, blurred vision, blindness)
- Mid epigastric pain (due to swelling of Glisson’s capsule of the liver)
- Signs: pulmonary edema, oliguria, cyanosis
» Risk factors?
- Nulliparity
- Age >40, or <18
- High BMI
- Prev pre-eclampsia
- FHx
- HTN, DM, GDM
- Vascular\connective tissue ds
- Thrombotic ds (antiphospholipid, thrombophilia)
» What tests to order?
- Labs:
- CBC
- Coagulation profile and platelet count (DIC, HELLP)
- Peripheral smear (?): hemolysis (HELLP)
- Liver enzymes: ALT\AST (HELLP)
- Serum creatinine + uric acid
- 24-hr urine collection for protein and Cr (or urine dipstick)
- Head CT, only if:
- Sudden severe headache
- Focal neurological deficits or altered mental status
- Seizures w\ prolonged postictal state
- Atypical presentation of pre-eclampsia
- Fetal wellbeing:
- US, doppler, CTG monitoring, BPP
» Diagnostic criteria of severe pre-eclampsia? (>20 wks of gestation)
- BP >160\110 (on 2 occasions + at least 6 hrs apart)
- Proteinuria (>5 grams in a 24-hr collection)
- Symptoms of severe features
» Management of severe pre-eclampsia?
- Stabilize the pt (ABCs)
- Admit to a specialist unit
If < 34 wks:
- Dexamethasone (4 doses of 6 mg every 12 hrs): to accelerate fetal lung maturity
- MgSo4 (4 g IV over 20 mins -> constant IV infusion -> continued 24 hrs post-partum)
- If signs of toxicity (↓ BP, HR, UO, reflexes, respiratory depression) -> give IV calcium gluconate
- Lower BP -> IV hydrazine or labetalol (aim for DBP of 90-100)
- Monitor for complications:
- Eclampsia (seizures) -> give IV benzodiazepines
- Vaginal bleeding (abruptio placenta)
- Oliguria (renal insufficiency)
- Fetal well-being
- If mother or fetus are uneatable -> deliver!
If > 34 wks:
- Give MgSo4 and continue 24-hrs post-partum
- Deliver:
- If mom and fetus stable -> induce labor with IV oxytocin and amniotomy
- If mom or fetus unstable -> C section